Surgical removal of severe hemorrhoids is more effective in the long run than tying them off with rubber bands

Surgical removal of severe hemorrhoids is more effective in the long run than tying them off with rubber bands, a less invasive treatment alternative, according to a new review of studies.

The review found no significant difference in patients' acceptance of each technique, "implying patients' preference for complete long-term cure of symptoms" despite the pain and higher risk of complications following surgery.

Rubber band ligation, or RBL, involves a rubber band placed around the base of the hemorrhoid, cutting off circulation, causing the hemorrhoid to wither away, generally within two weeks. This procedure had a success rate ranging from 69 percent to 94 percent, the study found, and was equal to surgery in terms of relieving the most common symptoms. However, surgery "achieved better overall cure rate" because patients undergoing RBL were more likely to need future treatment.

The review appears in the July issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Lead researcher Venkatesh Shanmugam of the Aberdeen Royal Infirmary of Aberdeen University in Scotland says that the study was done because none of the usual treatments -- diet change, rubber bands or surgery -- had previously been identified as better. This review involved 206 patients in three different studies.

Hemorrhoids are classified by degree of severity, with fourth degree the worst. The review suggests that surgery might be adopted as a treatment of choice for hemorrhoids classified as third or fourth degree and those that re-occur after RBL, and that RBL might be adopted as a treatment of choice for first- or second-degree hemorrhoids.

Dietary adjustments and bulk-forming agents generally are the first line of treatment. Numerous ointments are available to treat hemorrhoid symptoms but the review says that there is "little objective evidence of their efficacy."

Hemorrhoid disease is ranked first among the diseases of the rectum and large intestine. About half the U.S. population has experienced hemorrhoids by age 50. Men are more frequently afflicted than women, and the peak incidence of the disease occurs between the ages of 45 and 65.

Although patients undergoing RBL spent significantly fewer days away from work than patients subject to surgery, the reviewers say the escalating cost of repeated RBL procedures needs to be considered before definite conclusions are reached about the relative economic effect of the two procedures.

The review also made note of stapled hemorrhoidopexy as a new alternative to surgery, indicating that its standing as a treatment alternative awaits evaluation of the long-term results of the procedure.

Scott Thornton, M.D., a surgeon at Bridgeport Hospital in Connecticut and an assistant professor at Yale University School of Medicine, says that RBL involves "pain of half the volume and duration" of surgery. He says that RBL prompts complications in only about 1 percent of cases as compared with surgery, which prompts complications in 5 percent to 8 percent of cases.

"My own view is that RBL is pretty darn effective as a first treatment option," Thornton says. "I'll bet," he adds, that if the reviewers "were taking care of hemorrhoids of their own, they would opt for rubber band ligation because there is a very significant amount of pain involved with an excisional hemorrhoidectomy."